Children orphaned by AIDS in Uganda: Can they thrive under orphanage care?
Priscillah Rukundo and Marguerite Daniel, University of Bergen, Norway
Care for orphaned children is one of the major challenges facing AIDS-affected communities. Usually orphaned children are cared for by extended families; alternative living arrangements may include orphanages and child-headed households. This study focuses on orphanage care to (1) identify coping strategies used by orphaned children to deal with various challenges and (2) explore ways in which orphanages contribute to orphaned children’s wellbeing. Twelve children living in an externally-funded, family-style orphanage were interviewed. Staff members from the same orphanage and from two other organizations caring for orphaned children (six in total) were interviewed. Challenges faced by the children included mourning the loss of parents, longing to meet relatives and stigmatization of HIV positive children. The children coped by drawing on their faith, making friends and by avoiding and ignoring. The children’s basic needs were well provided for by the orphanage but there was a gap in psychosocial support. Connections with relatives were lacking for several children.
Care for orphaned children is one of the major challenges facing AIDS-affected communities especially in sub-Saharan Africa. Governments with limited budgets lack financial resources to invest in orphaned and vulnerable children and responsibility usually falls on extended families who are often living in poverty and struggle to adequately care for orphaned children. AIDS is one of the main causes of orphanhood in SSA (UNICEF, 2006). In 2010, it is estimated that globally, there were approximately 16 million children orphaned by AIDS (UNAIDS, 2010). Uganda was among the first countries to be hit hard by AIDS (Hunter, 1990) and currently it is estimated that 15% of children under 18 have been orphaned although under broader definitions of vulnerability, 51% of children in Uganda are considered critically or moderately vulnerable (Kalibala et al., 2012). The high death rate among young adults and the increase in the number of orphaned children has weakened the traditional social support systems provided by extended families (Foster, 2004, Madhavan, 2004). Some extended families are not able to provide adequate care resulting in alternative living arrangements such as, orphanages (Csáky, 2009) and child-headed households (CHHs) (Mavise, 2011, Daniel and Mathias, 2012). Some non-governmental organizations (NGOs), community-based organizations (CBOs) and faith-based organizations (FBOs) also provide care and assistance to this group of children (Currie and Heymann, 2011).
Abebe (2009, p.76) contends that there are “two polarized theories of care”. The first is a theory of ‘social rupture’ which describes the collapse of the extended family under the burden of orphan care and the second is a theory of ‘social resilience’ which sees orphaned children as “well looked after by extended families and communities.” Global organizations such as UNICEF subscribe to the first theory (Abebe, 2009) and, while promoting care in the family, they call for external interventions to enable it. They oppose institutional care and believe all children should be under the care of an adult (UNICEF et al., 2004) and hence have tended to ignore orphanages and child headed households. However, Abebe (2009) notes that external interventions ought to address structural causes of poverty and marginality, rather than further increasing inequality through selective support of orphans in economically vulnerable communities. A recent report (Mann et al., 2012) acknowledges that, in the light of the growing numbers of children in residential care in developing countries, there is an urgent need for more information about the phenomenon.
This study focuses on orphanages. Research on orphanages is scarce. Several of the studies, which are available, are about Romania and a few European countries that still have some forms of institutional care where children lived under very difficult conditions (Browne et al., 2006, Rutter, 1998, Chisholm, 1998). Current research also shows that children living in orphanages and other forms of institutional care are among the most vulnerable and are at risk of abuse, exploitation, developmental damage, mental distress and maladaptive behaviours (Browne, 2009, Csáky, 2009, Wolff and Fesseha, 1998). Most literature on institutional care for orphaned and vulnerable children is generally negative and institutionalization of children is discouraged. In Western countries, institutionalization has lost popularity and the process of deinstitutionalization is ongoing where institutional care is being replaced with community-based care or foster care (Mulheir et al., 2007). In 2009 the General Assembly of the UN adopted a resolution on “Guidelines for the Alternative Care of Children” to encourage governments to support families to care for children, prevent separation and promote reintegration where alternative care was necessary (UN, 2010).
In countries like Uganda where there are high numbers of orphaned and vulnerable children in a context of poverty and socio-economic deprivation, the existence of institutional care is a reality (Kalibala et al., 2012). Walakira et al. (2014 : p.145) note that there is a growing number of children in Uganda living under institutional care in spite of the Government’s National Alternative Care Framework which views institutional care as a last resort after exhausting all other alternatives (“family reunification, kinship and community care, domestic adoption, foster care, and intercountry adoption”). Walakira et al. (2014, p, 145) also contend that the lack of government enforcement of recommendations for running orphanages and Western initiated charitable aid are driving the proliferation of institutions for residential care of children in Uganda. It is estimated that there are as many as 50,000 children living in orphanages (Walakira et al., 2015) and that while there are approximately 800 residential care institutions in the country, fewer than 35 are licensed by the Ministry of Gender, Labour and Social Development (MLGSD) (Ogwang, 2015).
Table 1: Summary of policy and legal framework development to help orphans and vulnerable children
UN Convention on the Rights of the Child
The Children’s Act
National Orphans and Other Vulnerable Children Policy, MGLSD*
UN Guidelines for the Alternative Care of Children
Uganda National Framework for Alternative Care, MGLSD
National Strategic Programme Plan of Interventions for Orphans and Other Vulnerable Children, MGLSD
The Children Approved Homes Rules, MGLSD
Attempt to amend the Children’s Act to reflect Alternative Care Guidelines
6 August 2015 Bill withdrawn
*MGLSD = Ministry of Gender, Labour and Social Development
Table 1 summarises developments over time in the policy and legal framework to help children, in particular orphaned and vulnerable children. Developments in Uganda have followed the UN Convention and the Guidelines on Alternative Care. Most of the Ugandan documents are easily available, but an extensive internet search, including of the Ministry’s website, was not able to find the MGLSD’s 2011 Uganda National Framework for alternative Care in its original form. There is a website managed by an international NGO (http://www.alternative-care-uganda.org/alternative-care-framework.html) and presentations by Ministry officials (Ogwang, 2015) as well as articles by Walakira and colleagues (2015, 2014) that all present a very uniform perspective on the document, but access to the original document might have enabled a more critical discussion. The key contents of the alternative Care Framework – as presented by the international NGO - are shown in Table 2.
Table 2: Summary of contents of Alternative Care Framework
Response priorities (in order)
1. Keep the family together, prevent separation
2. Emergency care
3. Reunification and kinship care
4. Foster care
5. Domestic adoption
6. Inter-country adoption
Not listed as priority, but commented upon
1. Special needs respite or residential care
2. Orphanages. Comment: “long term residential care should be avoided”
Source: International Child Campaign http://www.alternative-care-uganda.org/alternative-care-framework.html (accessed 29 January 2016)
As we noted, literature on orphanages is scarce; this is especially so in the context of SSA countries though orphanages and general institutionalization of children are becoming increasingly popular in some African countries (Mann et al., 2012). Traditionally, institutionalization of children was not a common practice in African communities, it was introduced by missionaries during the colonial period and currently there are several different types of organizations providing institutional care for children (Tolfree, 1995). Some are in the form of educational institutions where children are placed in boarding schools and hostels and provided with care and assistance by different organizations (Christiansen, 2005). In the Ugandan context, institutional care for education is perceived rather positively. In her study about children and institutions for childcare, Christiansen (2005) argues that both adults and children like and desire institutional living, they associate it with good living, a better future, and escape from poverty and mistreatment by some caregivers. Empirical studies on orphanages in SSA include two quantitative surveys which compare children living in institutions with those living in the community in terms of motor development (Jelsma et al., 2011) and health, emotional and cognitive functioning as well as physical growth (Whetten et al., 2009, Whetten et al., 2014). The first was conducted in Cape Town, South Africa and the second is a longitudinal study in five poor countries including Ethiopia, Kenya and Tanzania. Both studies concluded that children in institutional care do not do worse than those in community care and in some conditions may do better. Two further studies occurred in South Africa, both qualitative, with one study finding that institutional care absorbs a disproportionate number of HIV positive children (16% of residents across 34 institutions in 4 cities compared to 1.9% of children in the general population) (Moses and Meintjes, 2010). The second study concentrated on psychosocial and developmental issues of adolescents in a single institution in Gauteng and found both advantages (material and emotional support) and disadvantages (stigma linked to living in a facility associated with HIV) (Van Vilsteren et al., 2011). A study in Botswana which sought the views of the children living in a residential facility found that they rated good access to food and schooling very highly but that they also felt a sense of separation from family and community (Morantz and Heymann, 2010). In Mozambique, a study comparing children in NGO residential care with those in foster homes in the community, found that children in foster homes were more likely to experience abuse, neglect and maltreatment (Shibuya and Taylor, 2013). A recent study in Kenya found orphaned children in institutional care significantly more likely to have their basic material needs met than those in community care (Embleton et al., 2014). All these studies noted that there are some significantly positive aspects to residential care. The baseline survey of child care institutions in Uganda by Walakira et al. (2015) assesses how well residential care institutions are doing in operationalising the Framework for Alternative Care and the well-being of the children living there. They found that only 13 percent of the children had lost both their parents, that many spent long periods of time in the institutions and that less than half the children had regular contact with surviving parents or relatives.
Residential (institutional) care refers to care provided to groups of children outside the family base (Mann et al., 2012). Orphanages refer to institutions where all the children who are residents have lost one or both parents but this term is often inaccurately used (Dozier et al., 2012). Several authors note that there may be great variations in the quality of care given with particular variation between dormitory-style residential care and family-based care modelled on SOS Children’s Villages (Mann et al., 2012, Abebe, 2009).
The overall aim of this paper is to explore whether orphaned children living in (family-based, externally funded) orphanages in Uganda can thrive. Sub-objectives include, firstly, to identify challenges faced by orphaned children and their coping strategies and, secondly, to explore ways in which orphanages contribute to orphaned children’s ability to thrive.
1.2 Theoretical framework
Ickovics and Park (1998, p.238) suggest that thriving implies that “challenge can provide the impetus for growth and greater well-being”. Carver (1998, p.247) defines thriving as a situation where “a person can be better off after adversity than beforehand” and distinguishes it from resilience where a person simply returns to their prior situation after adversity. With resilience a person may develop a resistance to the adversity or the ability to ‘bounce back faster’ when adversity hits again, but a person who thrives will be able to function at a higher level. Carver (1998) admits thriving may be hard to evaluate but he suggests three features to look for, namely: skills and knowledge; confidence; and strengthened personal relationships. Acquired skills and knowledge may help a person to deal with future problems and uncertainty with greater flexibility. Surviving adversity (along with increased skills and knowledge) can lead to greater confidence and sustain the person’s efforts to cope. Adversity has social consequences, for example, if a person experiencing adversity receives help, this can develop a sense of security in the relationships involved. Thriving is transformative in the sense that “it is contingent on a fundamental cognitive shift in response to a challenge” (O'Leary, 1998, p.430)
2.1 Study sites
The study was carried out in three organizations: a Watoto Village (Ssubi) Village, a SOS Children’s Village (Kakiri), and a community-based organization, Ashinaga-Uganda. At Ssubi Village, everything is provided on-site: accommodation, schooling, church, and healthcare. The accommodation consists of 84 houses, each with a ‘mother’ and eight children - both girls and boys - of different ages. At Ssubi, both children and staff were interviewed and at the other two organizations, only staff members were interviewed.
Nineteen people participated in the study. Twelve were orphaned children aged 13-15 years, 6 boys and 6 girls, from Ssubi Village (6 of them were HIV positive), 3 ‘mothers’ from Ssubi Village, 2 caregivers from SOS Children’s Village and 2 social workers from Ashinaga-Uganda. All children who were recruited were articulate, confident and “thriving” as described by the administrator who helped in selecting those who participated; this was the inclusion criteria. We interviewed ‘mothers’, caregivers and social workers so as to evaluate their opinions towards orphanage care. In addition a former resident of one of the Watoto orphanages was interviewed.
2.3 Data collection and analysis
Data were collected mainly through in-depth, face-to-face, semi-structured interviews where open-ended questions were asked. Data were analysed using the ‘thematic networks’ method of qualitative analysis, which consists of six steps, that is: coding the material, identifying themes, constructing networks (basic themes, organizing themes and global themes), describing and exploring thematic networks, summarizing thematic networks and interpreting patterns (Attride-Stirling, 2001). Data were coded based on the study objectives and other salient findings (this formed the coding frame). Textual data obtained from the field were dissected according to the coding frame. Themes were formulated out of the coded text by re-reading the already coded text such that they were broad and specific enough to represent all data. The formulated themes then became the starting point for the construction of the thematic networks by further grouping them under “basic themes, organizing themes and global themes” such that data were encapsulated into more manageable and meaningful themes. According to Attride-Stirling (2001), when constructing the thematic networks, the themes mentioned above become or are simply renamed basic themes. To obtain organizing themes, basic themes that had close meaning were clustered together. These were more concrete and representative of the original textual data than what was represented by the basic themes. The organizing themes were further synthesized into broader categories - the global themes. Finally, the information on the thematic networks was compared with the original data to ensure that data were correctly extracted from textual data, coded and interpreted.
2.4 Ethical clearance and informed
Ethical clearance was obtained from three sources; the Norwegian Social Sciences Data Services, the Uganda National Council for Science and Technology and from the participating organizations. Consent was sought from children, caregivers and the social workers. Informed consent for the children was first obtained by proxy (i.e. their forms were given to the person with legal guardianship over them for signing since they were below 18 years of age). However, he did not sign them, he simply stated that the selected children could participate. Since the interviewed children were old enough to understand what the study was about, an informed consent form was given to each for signing (an assent). The main aspects of consent such as the level and type of participant involvement, confidentiality and freedom to withdraw from the study at any time were clearly explained to all participants. When dealing with vulnerable children who have experienced the death of a parent and possibly other traumatic events, ethical behaviour requires more that informed consent - talking about personal experiences may be upsetting and painful (Skovdal and Abebe, 2012). We gave the children the opportunity to have their ‘mother’ with them if they so wished, but none availed themselves of the opportunity.
The structure of the results is based on the issues raised in the objectives: challenges, coping strategies and the ways in which orphanages contribute to orphaned children’s ability to thrive. Results represent views of the interviewed children, the old boy from one of the Watoto Villages and ‘mothers’ (from Ssubi); caregivers (from SOS village); and social workers (from Ashinaga).
The study established that children experienced challenges like stigma, cultural, academic and language problems, theft, bullying and few cases of caregiver mistreatment. The HIV positive children faced challenges related to their health status and all children mentioned that living as orphaned children was a big challenge. For purposes of this paper, three challenges will be discussed in detail.
3.2 Challenges resulting from orphanhood
All child participants were orphaned. They mourned the loss of their parent(s) and this aroused emotional feelings of sadness: “I feel sad when my mind goes back home and I remember how my mother died.” David
Some cited unique things that their parents would do for them that no other person can do: “When I sit back and remember the good things my mother used to do for me like birthday surprises. It makes me feel sad because here no one remembers my birthday or even celebrates it.” Ryan.
Challenges of orphanhood were also related with joining the orphanage at a tender age (some as young as 3 years). Some children who joined at such an age mentioned that they had not met any of their relatives and longed to meet them. Others remembered and missed their relatives: “Relatives teach community and village activities, for example, grazing. I also miss my grandmother because she used to take me to the garden with her and she would teach me a lot of things”. Ritah
‘Mothers’ revealed that at times, some children ask them about their origins, families and relatives: “They ask themselves so much about their biological parents. Those who came when they were very young, when they grow up they get to know that we are not their biological parents and they want to know the truth. Some of them even find it hard to call us ‘mother’.” ‘Mother’.
‘Mothers’ revealed that administrators try to find such children’s relatives but in some cases this has not been possible: “…We try to trace their relatives and we invite them to visit them but some of them we have totally failed to find any of their relatives.” ‘Mother’.
3.3 Challenges associated with being HIV positive
Six of the interviewed children were HIV positive. They experienced additional challenges related to their HIV status like stigma, marginalization, physical abuse and naming. One girl who suffered skin discoloration from herpes zoster described her experience: “Some children make fun of me about my skin. They refer to me as a Black American. Others call me black charcoal.” Emily.
Social workers’ indicated that many HIV positive children in orphanages are often stigmatized especially those on medication or those with visible AIDS symptoms. However, when ‘mothers’ and caregivers were asked about the issue of stigma, they mentioned that stigma was not one of the challenges children experienced.
3.4 Academic challenges
Some children found it hard to concentrate and perform well in school because of various hindrances: “…Because I love football yet football does not require me to go to class. I actually find it hard to go to school and concentrate because I do not like school.” Daniel.
However, both orphanages had a vocational school for children with serious academic challenges. From the social workers’ point of view, education in most orphanages is generally poor because children remain within orphanages and have no opportunity to interact academically with other students outside: “Education in orphanages is not really good even when children are free with less work because there is no competition so they do not perform well.” Social worker.
Most of the of the children, ‘mothers’ or caregivers did not identify education at the orphanages as bad, apart from two children who had individual academic challenges of poor performance. This contrasts what social workers said.
3.5 Coping strategies
The children discussed strategies which enabled them to cope despite the challenges that they experienced.
All Watoto founded orphanages are Christian based and Christianity is a key feature of the orphanages. There is a religious leader (commonly referred to as pastor) stationed at the orphanage and other pastors from different churches visit the orphanage to preach and teach the children. Religion was found to be one of the ways through which children coped with different challenges: “The Lord says that everyone is special and at the same level with the rest before him. Whenever, I remember this verse, I feel that I am very important no matter what other people may say or no matter what I am going through”. Ritah
Many children mentioned that whenever they had a problem, they prayed; pastors, mothers and other staff also prayed for them and encouraged them: “Encouraging them also makes them feel happy, most of them are Christians and believe in God, so when you preach to them and encourage them they feel happy.” ‘Mother’.
Coping by making friends and through sports and games
Children who had academic challenges and problems of being stigmatized received support from friends who comforted and consoled them. Those with academic challenges revealed that apart from going back to their teachers for extra help, their friends helped them with their class work: “I have two good friends, they are simple and helpful. One is good in Mathematics and another in Science. They help me with my classwork.” Fred.
Children made friends with fellow children, sometimes strategically, with those they had similar interests with. To some, it was a coping mechanism: “Keith is my best friend. He is very bright and I am also very intelligent. I made him my friend so that I can excel. He is always 1st and I come 2nd.” Joel.
Apart from making friends, children enjoyed a variety of sports and games for instance, football, netball, volleyball and cricket. They had clubs such as the dance, music and drama club, sports club, grooming club, literacy club and life skills club. All children belonged to at least one club and participated in one or more sport. This gave them a chance to interact and play with one another and in the long run it helped them to forget some of their problems because participating in such activities occupied their minds. For example the quote from Daniel above shows how sport takes his mind off his academic difficulties.
Coping through counselling
Counselling involves giving advice to someone especially by a knowledgeable person. There was a school counsellor who encouraged and gave emotional support to children who experienced academic and orphanhood-related challenges. The children also mentioned other staff at the orphanage and their teachers as potential sources of counselling: “For example, the pastor advises us on different challenges and he prays for us. But also the administrators, they tell us that whenever any of us has a problem we should always go and talk to them.” Daniel.
‘Mothers’ mentioned that they also counselled and encouraged children especially those with problems of accepting them: “The ‘mothers’ normally talk to them with kind words, they explain to them that even if they are not their real mothers, they are there for them and are willing to do everything for them, this keeps them for some time though the rejection comes again.” ‘Mother’.
Coping by avoiding and ignoring
Avoiding and ignoring were used as a last resort means of coping. Children who experienced challenges of stigma, abuse and bulling revealed that whenever they reported such cases to the administration, those in wrong were given minor punishments like sweeping or mowing the compound. Due to the minor punishments given, the abusers never quit these bad deeds and the affected chose to ignore or avoid: “I just leave those who bully me because when I report them say to the administration, they are given minor punishments and after they beat me or other children who report them.” Ritah.
3.6 The contribution of orphanages to children’s well-being
Some orphaned children may not have an adult to take care of them especially when relatives find it difficult to look after additional children due to limited resources. When such children get an opportunity to enroll in any charity organization for instance, an orphanage, they may find it a comfortable place to live in compared to their former homes. The orphanage contributed to children’s well-being in different ways. Both orphanages provided good food, medication, accommodation, education and care for children. When asked what it was like living at the orphanage, most children stated that it was good.
“It is now three years since I came here, it has been good, I have many friends, we have sponsors and life is just easy.” Ritah.
“It has been good, they care for us and they do not remind us of our past.” Joyce.
When asked how living at the orphanage compared with their former homes, many children seemed to prefer living at the orphanage. They revealed that the orphanage provided almost all necessities that they often lacked in their homes.
“I used to stay with my stepmother and she never used to treat me well. I can say that I was not cared for but here you are treated like a real child…” Joyce.
“Relatives were not able to provide most things, going to school was different, you wake up, first do chores and then go to school, even on coming back home, you have work to do. But here we are provided with almost everything. Schools are within. You just wake up and go to school. No school fees and it makes schooling easy and interesting.” Daniel.
The orphanage staff comprised different people: administrators, ‘mothers’, teachers, counsellors and religious leaders. These played some role in helping children to deal with different challenges faced. Sponsors play a vital role; they financially support all orphanage activities and services. They provide money for building houses and schools, and for the provision of food and medication. These are some of things that enable children to live a more comfortable life as explained by the old boy from Ssubi Village.
“…They have sponsors who provide money to buy different things, they have good houses and they sleep well, schools are within and they have free education. Their surrounding is good. So it is such things that enable some children to thrive because I can say that all of them do not have any of the things that they receive back at home.” Old boy.
Both orphanages provided AIDS prevention and education programs plus counselling services to children. All interviewed children had knowledge about AIDS prevention. The orphanages carried out HIV testing, some children confirmed to have been tested and told their status. Those who were HIV positive knew it and they received treatment from the Village clinic and MildMay International (an AIDS charity organization). Nonetheless, social workers had contrasting ideas on the issue of AIDS education in orphanages. They stated that there is a lot of stigma in most orphanages and there is limited AIDS education.
“But, in orphanages there is less AIDS education due to fear of stigma. For example, if they teach about signs and symptoms, those with AIDS and with any symptoms are stigmatized or those that are on medication, other children ask them why they are ever taking medicine which stigmatizes them.” Social worker.
But it was clear that the orphanages had AIDS prevention programs, children had good knowledge about the epidemic and AIDS prevention and its related programs were not among the ways through which children experienced stigma as expressed by the social workers.
3.7 Knowledge, confidence and strengthened relationships
The children do find some things difficult to cope with, particularly grief for their late parents: “Yes, I feel sad sometimes, especially if anything reminds me of my mother, she was so good and I miss her.” Joel
However, they also demonstrated growth and development in the aspects of ‘thriving’ mentioned above.
“When someone encourages me in what I am doing I feel like they care about me and wish me the best. I know I have value and I am important”. Deborah
“When I am respected, I feel valued. Because when someone respects you, it means that they find you a useful person and this makes me feel that I am important. When we are preached to that we should not let others look down on us, this makes me feel good. I am assured of the value that I have”. Anna
They know how to respond in difficult situations: “Even when others abuse and stare at me, I just do not mind them. Yes, it makes me sad but it does not make me avoid them”. Emily
Mothers require them to help and they take positions of responsibility: “I am a cell leader, I teach children and they listen to me. It makes me feel important and of value.” David
Thriving, as defined in the introduction, means that a person is better-off, with greater well-being after adversity than beforehand (Carver, 1998, Ickovics and Park, 1998). Although all the participating children had been identified as “thriving” by the orphanage staff, the children’s own accounts indicate that this can be questioned. After considering orphanage provision for basic and psychosocial needs, we make use of Carver’s (1998) suggested features of thriving, namely: skills and knowledge; confidence; and strengthened personal relationships, to consider whether or not the children in this study could be described as thriving.
4.1 Guaranteed basic needs
Children reported uninterrupted provision of material and non-material basic needs such as food, shelter, education, clothing and medical care. The interviewed social workers confirmed that children in externally-funded, family-style orphanages are more assured of basic needs compared to children who grow up in communities or with their relatives. The majority of orphaned children in SSA are cared for by their extended families (Hosegood, 2009) and in a recent study in Rakai District in Uganda the quality of this care was rated at the highest level (Karimli et al., 2012). However numerous studies in SSA report that orphaned children and others affected by HIV are more likely to be malnourished, be withdrawn from school or perform badly, to fall ill and have poor access to health care (Madhavan and Townsend, 2007, Kidman et al., 2010, Cluver et al., 2012, Guo et al., 2012). In contrast, the very few studies available on children in residential care in SSA consistently report the steady provision of material needs with good access to schooling and health care (Morantz and Heymann, 2010, Whetten et al., 2009, Van Vilsteren et al., 2011, Embleton et al., 2014). While our findings support this conclusion, we acknowledge that we found no recent studies on dormitory style orphanages where conditions might not be as good. An older study on residential care in developing countries in general, presented various examples of institutions where children’s basic needs were not adequately met (Tolfree, 1995).
4.2 Psychological needs
Many orphanages concentrate on providing basic needs while neglecting other needs, especially psychological/emotional needs (Mann et al., 2012). According to Ebersöhn and Eloff (2002), psychological needs may not be easily visible and not taken care of as compared to basic needs. In our study, some children mentioned that they often mourned their late parent(s), which at times made them sad; yet, apart from being counselled, there were no other clear ways through which their psychological problems were solved. Institutionalization of children is also said to cause significant developmental deficits that include: attachment disorders, developmental delays in social, behavioural, and cognitive aspects, which are at times lifelong (Browne, 2009, Dozier et al., 2012, Johnson et al., 2006, Csáky, 2009). This is one of the reasons why many researchers and international organizations are against institutionalization of children; they continue to look at it as an insecure way of bringing up children.
4.3 Coping with challenges
All children in study were faced with different challenges. They included physical abuse or naming, being HIV positive, poor performance at school, stigma and mistreatment by some caregivers. Previous studies on institutional care have highlighted some of the challenges that the study confirmed. A study carried out in Botswana reveals that approximately 25 percent of the children reported verbal and physical abuse by some caregivers (Morantz and Heymann, 2010). Similar forms of abuse occur outside institutions as well. For instance, in their study, Cluver and colleagues (2007) report that orphaned children experienced abuse by being beaten, shouted at, neglected and at times raped. Shibuya & Taylor (2013), in a study in Mozambique, found that children in foster homes were more likely to be abused and maltreated than those in residential care. According to Tolfree (1995), the potential for child abuse is high in most developing countries due to lack of proper mechanisms for investigating allegations of child abuse or other violations of children’s rights. In China, different disadvantages of institutional care were highlighted in four different orphanages. They included stigma, administrative restrictions, psychological and emotional despair (Zhao et al., 2009).
Despite the challenges experienced, children had coping strategies which enabled them to deal with those challenges. They included counselling, making friends, sports and games, religion, ignoring and avoiding. Less is documented on the strategies of coping with different challenges in the context of institutional care. In their study, Morantz and Heymann (2010) mention that the social worker at the institution helped children cope with various challenges and the ‘mothers’ though few and untrained in counselling, were the primary caregivers who dealt with children’s mental and health problems. Relatedly, in our study, ‘mothers’ were said to be the number one person children relied on and went to in case of a problem. Some of the coping strategies that the study confirmed are similar to those used by orphaned children living with relatives or in communities i.e. coping by forgetting, accepting, adjusting, counselling and encouragement (Fjermestad et al., 2008, Hutchinson, 2011). Others include coping by active participation in income generating activities that contribute to household survival and constructing positive identities (Skovdal, 2009). Our findings point to one challenge that remains without a coping mechanism: unpreparedness for life after orphanage care.
All the children participating in the study were in school, receiving additional HIV education and engaging in a range of clubs and sports all of which were contributing to their skills and knowledge. Yet the quality of their education was questioned by the social workers who saw the fact that schooling was provided within the Village as depriving children of valuable academic interaction and competition with children in other schools and the community. The children themselves note that going to school is easy, there are no chores to be done beforehand and no concerns over finding the money for fees. Often it is a challenge that develops and hones life skills and Abebe (2009) contends that children in the SOS Children’s Village in Ethiopia had fewer social skills and seemed unprepared to cope with life on leaving residential care. Surviving adversity as well as the development of skills and knowledge, generate confidence (Carver, 1998), but when life is easy, the lack of challenge may result in complacency rather than confidence. The children also mentioned the importance of friendships and some reported being highly strategic in who they chose as their friends so that they would be encouraged to excel in school, for example. Other studies report the significance of friendship relationships and how they contribute to children’s ability to cope with hardship and even thrive (Skovdal and Ogutu, 2012). Although friendship relationships seemed to be strong and supportive, the children reported longing to know their relatives and ‘mothers’ stated that although the administration tried to trace relatives, it was not always possible. The lack of a network outside the orphanage isolates the children within and contributes to difficulties in coping with life after orphanage care (Abebe, 2009). Some of the children in our study demonstrated self-confidence and competencies such as leadership and ability to take responsibility.
In summary, then, within the bounds of the orphanage, the children could be described as thriving – they had skills and knowledge, confidence, and supportive relationships. Certainly in material terms they are better off in the orphanage than they were before. However, they have no experience or interaction with the world outside the orphanage and they lack connection with relatives and people outside of the orphanage. It is questionable whether their skills & knowledge and friendships inside the orphanage will help them to deal with future problems once they leave the orphanage.
Today, institutional care continues to be viewed in comparison to the ‘Romanian’ kind of orphanages that existed in the early 1990s, which are often reported about negatively (Dozier et al., 2012). But it should be noted that institutional care can provide an important alternative when community based care fails and in some situations, it may even be preferred. Mann and colleagues (2012) note that residential care is a growing phenomenon in SSA and cannot be ignored simply because international institutions such as UNICEF prefer family-based care. While we agree that community based care should be the first priority for orphaned children and that families looking after these children should be given the best support possible, we argue that institutional care still has a place in societies affected by HIV and AIDS.
The study comprised a small number of child participants who were purposively selected by two administrators and some ‘mothers’. Therefore, participants’ views may not be representative of other children at the orphanage and may in fact represent views of the gatekeepers who selected them. The study mainly relied on data from interviews. Systematic and extensive observation could have added rich detail to the interview data. There was no use of other sources of information like documents, which could have provided additional information. Interviews were not audio recorded, which may have compromised the validity and reliability of the data.
This study explored the well-being of orphaned children, some of whom were HIV positive, living in a family-style, externally-funded orphanage in Uganda. Although their material needs (food, accommodation, education and health care) were well taken care of, they still faced some psychosocial challenges such as on-going mourning for lost parents and a longing to make contact with relatives. Some of the HIV positive children experienced stigma. They children had various ways of coping with the challenges, which include drawing on friendship relationships and also avoiding or ignoring some challenges like stigma. While the orphanage certainly improved the children’s material well-being, what the children lacked was contact with their relatives and interaction with the outside world. Within the bounds of the orphanage the children could be described as better off than they were before, possibly even thriving, but the skills, knowledge and relationships provided by the orphanage may not adequately equip them to solve future problems once they leave orphanage care.
We are grateful to our participants who took time to participate in our study. Special appreciations go to the three organizations that accepted us to conduct this study.
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Department of Health Promotion & Development
University of Bergen
PO Box 7807
Department of Health Promotion & Development
University of Bergen
PO Box 7807
 NGOs, CBOs and FBOs are all forms of civil society, as opposed to the government sector. For the purposes of this paper we are defining NGOs as organisations initiated outside the community (they can be national or international level); CBOs are organisations driven by local residents (they are sometimes called grassroots organisations) and FBOs are driven by religious organisations